Multi-institutional questionnaire-based survey on online adaptive radiotherapy performed using commercial systems in Japan in 2023

In this study, we aimed to conduct a survey on the current clinical practice of, staffing for, commissioning of, and staff training for online adaptive radiotherapy (oART) in the institutions that installed commercial oART systems in Japan, and to share the information with institutions that will implement oART systems in future. A web-based questionnaire, containing 107 questions, was distributed to nine institutions in Japan. Data were collected from November to December 2023. Three institutions each with the MRIdian (ViewRay, Oakwood Village, OH, USA), Unity (Elekta AB, Stockholm, Sweden), and Ethos (Varian Medical Systems, Palo Alto, CA, USA) systems completed the questionnaire. One institution (MRIdian) had not performed oART by the response deadline. Each institution had installed only one oART system. Hypofractionation, and moderate hypofractionation or conventional fractionation were employed in the MRIdian/Unity and Ethos systems, respectively. The elapsed time for the oART process was faster with the Ethos than with the other systems. All institutions added additional staff for oART. Commissioning periods differed among the oART systems owing to provision of beam data from the vendors. Chambers used during commissioning measurements differed among the institutions. Institutional training was provided by all nine institutions. To the best of our knowledge, this was the first survey about oART performed using commercial systems in Japan. We believe that this study will provide useful information to institutions that installed, are installing, or are planning to install oART systems.

Commissioning and dosimetric verification of volumetric modulated arc therapy for multiple modalities using electronic portal imaging device-based 3D dosimetry system: a novel approach

The purpose of this study was to validate an electronic portal imaging device (EPID) based 3-dimensional (3D) dosimetry system for the commissioning of volumetric modulated arc therapy (VMAT) delivery for flattening filter (FF) and flattening filter free (FFF) modalities based on test suites developed according to American Association of Physicists in Medicine Task Group 119 (AAPM TG 119) and pre-treatment patient specific quality assurance (PSQA).With ionisation chamber, multiple-point measurement in various planes becomes extremely difficult and time-consuming, necessitating repeated exposure of the plan. The average agreement between measured and planned doses for TG plans is recommended to be within 3%, and both the ionisation chamber and PerFRACTION™ measurement were well within this prescribed limit. Both point dose differences with the planned dose and gamma passing rates are comparable with TG reported multi-institution results. From our study, we found that no significant differences were found between FF and FFF beams for measurements using PerFRACTION™ and ion chamber. Overall, PerFRACTION™ produces acceptable results to be used for commissioning and validating VMAT and for performing PSQA. The findings support the feasibility of integrating PerFRACTION™ into routine quality assurance procedures for VMAT delivery. Further multi-institutional studies are recommended to establish global baseline values and enhance the understanding of PerFRACTION™'s capabilities in diverse clinical settings.

Development of shielding evaluation and management program for O-ring type linear accelerators

The shielding parameters can vary depending on the geometrical structure of the linear accelerators (LINAC), treatment techniques, and beam energies. Recently, the introduction of O-ring type linear accelerators is increasing. The objective of this study is to evaluate the shielding parameters of new type of linac using a dedicated program developed by us named ORSE (O-ring type Radiation therapy equipment Shielding Evaluation). The shielding evaluation was conducted for a total of four treatment rooms including Elekta Unity, Varian Halcyon, and Accuray Tomotherapy. The developed program possesses the capability to calculate transmitted dose, maximum treatable patient capacity, and shielding wall thickness based on patient data. The doses were measured for five days using glass dosimeters to compare with the results of program. The IMRT factors and use factors obtained from patient data showed differences of up to 65.0% and 33.8%, respectively, compared to safety management report. The shielding evaluation conducted in each treatment room showed that the transmitted dose at every location was below 1% of the dose limit. The results of program and measurements showed a maximum difference of 0.003 mSv/week in transmitted dose. The ORSE program allows for the shielding evaluation results to the clinical environment of each institution based on patient data.

Adapting a practical EPR dosimetry protocol to measure output factors in small fields with alanine

PURPOSE

Modern radiotherapy techniques often deliver small radiation fields. In this work, a practical Electron Paramagnetic Resonance (EPR) dosimetry protocol is adapted and applied to measure output factors (OF) in small fields of a 6 MV radiotherapy system. Correction factors and uncertainties are presented and OFs are compared to the values obtained by following TRS-483 using an ionization chamber (IC).

METHODS

Irradiations were performed at 10 cm depth inside a water phantom positioned at 90 cm source to surface distance with a 6 MV flattening filter free photon beam of a Halcyon radiotherapy system. OFs for different nominal field sizes (1 × 1, 2 × 2, 3 × 3, 4 × 4, normalized to 10 × 10 cm2 ) were determined with a PinPoint 3D (PTW 31022) IC following TRS-483 as well as with alanine pellets with a diameter of 4 mm and a height of 2.4 mm. EPR readout was performed with a benchtop X-band spectrometer. Correction factors due to volume averaging and due to positional uncertainties were derived from 2D film measurements.

RESULTS

OFs obtained from both dosimeter types agreed within 0.7% after applying corrections for the volume averaging effect. For the used alanine pellets, volume averaging correction factors of 1.030(2) for the 1 × 1 cm2 field and <1.002 for the larger field sizes were determined. The correction factor for positional uncertainties of 1 mm was in the order of 1.018 for the 1 × 1 cm2 field. Combined relative standard uncertainties uc for the OFs resulting from alanine measurements were estimated to be below 1.5% for all field sizes. For IC measurements, uc was estimated to be below 1.0%.

CONCLUSIONS

A practical EPR dosimetry protocol is adaptable for precisely measuring OFs in small fields down to 1 × 1 cm2 . It is recommended to consider the effect of positional uncertainties for field sizes <2 × 2 cm2 .

Simulation of consequences of using nonideal detectors during beam data commissioning measurements

BACKGROUND

Beam data commissioning is a core task of radiotherapy physicists. Despite multiple detectors available, a feasible measurement program compromises between detector properties and time constraints. Therefore, it is important to understand how nonideal measurement data propagates into patient dose calculation.

PURPOSE

We simulated the effects of realistic errors, due to beam commissioning with presumably nonoptimal detectors, on the resulting patient dose distributions. Additionally, the detectability of such beam commissioning errors during patient plan quality assurance (QA) was evaluated.

METHODS

A clinically used beam model was re-commissioned introducing changes to depth dose curves, output factors, profiles or combinations of those. Seventeen altered beam models with incremental changes of the modelling parameters were created to analyze dose changes on simplified anatomical phantoms. Additionally, fourteen altered models incorporate changes in the order of signal differences reported for typically used detectors. Eighteen treatment plans of different types were recalculated on patient CT data sets using the altered beam models.

RESULTS

For the majority of clinical plans, dose distributions in the target volume recalculated on the patient computed tomography data were similar between the original and the modified beam models, yielding global 2%/2 mm gamma pass rates above 98.9%. Larger changes were observed for certain combinations of beam modelling errors and anatomical sites, most extreme for output factor changes in a small target volume plan with a pass rate of 80.6%. Modelling an enlarged penumbra as if measured with a 0.125 cm3 ion chamber had the largest effect on the dose distribution (average pass rate of 96.5%, lowest 85.4%). On different QA phantom geometries, dose distributions between calculations with modified and unmodified models typically changed too little to be detected in actual measurements.

CONCLUSION

While the simulated errors during beam modelling had little effect on most plans, in some cases changes were considerable. High-quality penumbra and small field output factor should be a main focus of commissioning measurements. Detecting modelling issues using standard patient QA phantoms is unlikely. Verification of a beam model should be performed especially for plans with high modulation and in different depths or geometries representing the variety of situations expected clinically.

Characterization and commissioning of a new collaborative multi-modality radiotherapy platform

TaiChi, a new multi-modality radiotherapy platform that integrates a linear accelerator, a focusing gamma system, and a kV imaging system within an enclosed O-ring gantry, was introduced into clinical application. This work aims to assess the technological characteristics and commissioning results of the TaiChi platform. The acceptance testing and commissioning were performed following the manufacturer's customer acceptance tests (CAT) and several AAPM Task Group (TG) reports/guidelines. Regarding the linear accelerator (linac), all applicable validation measurements recommended by the MPPG 5.a (basic photon beam model validation, intensity-modulated radiotherapy (IMRT)/volumetric-modulated arc therapy (VMAT) validation, end-to-end(E2E) tests, and patient-specific quality assurance (QA)) were performed. For the focusing gamma system, the absorbed doses were measured using a PTW31014 ion chamber (IC) and PTW60016 diode detector. EBT3 films and a PTW60016 diode detector were employed to measure the relative output factors (ROFs). The E2E tests were performed using PTW31014 IC and EBT3 films. The coincidences between the imaging isocenter and the linac/gamma mechanical isocenter were investigated using EBT3 films. The image quality was evaluated regarding the contrast-to-noise ratio (CNR), spatial resolution, and uniformity. All tests included in the CAT met the manufacturer's specifications. All MPPG 5.a measurements complied with the tolerances. The confidence limits for IMRT/VMAT point dose and dose distribution measurements were achieved according to TG-119. The point dose differences were below 1.68% and gamma passing rates (3%/2 mm) were above 95.1% for the linac E2E tests. All plans of patient-specific QA had point dose differences below 1.79% and gamma passing rates above 96.1% using the 3%/2 mm criterion suggested by TG-218. For the focusing gamma system, the differences between the calculated and measured absorbed doses were below 1.86%. The ROFs calculated by the TPS were independently confirmed within 2% using EBT3 films and a PTW60016 detector. The point dose differences were below 2.57% and gamma passing rates were above 95.3% using the 2%/1 mm criterion for the E2E tests. The coincidences between the imaging isocenter and the linac/gamma mechanical isocenter were within 0.5 mm. The image quality parameters fully complied with the manufacturer's specifications regarding the CNR, spatial resolution, and uniformity. The multi-modality radiotherapy platform complies with the CAT and AAPM commissioning criteria. The commissioning results demonstrate that this platform performs well in mechanical and dosimetry accuracy.

Sensitivity and specificity of Varian Halcyon's portal dosimetry for plan-specific pre-treatment QA

PURPOSE

Developed as a plan-specific pre-treatment QA tool, Varian portal dosimetry promises a fast, high-resolution, and integrated QA solution. In this study, the agreement between predicted fluence and measured cumulative portal dose was determined for the first 140 patient plans at our Halcyon linear accelerator. Furthermore, the capability of portal dosimetry to detect incorrect plan delivery was compared to that of a common QA phantom. Finally, tolerance criteria for verification of VMAT plan delivery with Varian portal dosimetry were derived.

METHODS

All patient plans and the corresponding verification plans were generated within the Eclipse treatment planning system. Four representative plans of different treatment sites (prostate, prostate with lymphatic drainage, rectum, and head & neck) were intentionally altered to model incorrect plan delivery. Investigated errors included both systematic and random errors. Gamma analysis was conducted on both portal dose (criteria γ2%/2 mm , γ2%/1 mm , and γ1%/1 mm ) and ArcCHECK measurements (criteria γ3%/3 mm , γ3%/2 mm , and γ2%/2 mm ) with a 10% low-dose threshold. Performance assessment of various acceptance criteria for plan-specific treatment QA utilized receiver operating characteristic (ROC) analysis.

RESULTS

Predicted and acquired portal dosimetry fluences demonstrated a high agreement evident by average gamma passing rates for the clinical patient plans of 99.90%, 96.64%, and 91.87% for γ2%/2 mm , γ2%/1 mm , and γ1%/1 mm , respectively. The ROC analysis demonstrated a very high capability of detecting erroneous plan delivery for portal dosimetry (area under curve (AUC) > 0.98) and in this regard outperforms QA with the ArcCHECK phantom (AUC ≈ 0.82). With the suggested optimum decision thresholds excellent sensitivity and specificity is simultaneously possible.

CONCLUSIONS

Owing to the high achievable spatial resolution, portal dosimetry at the Halcyon can reliably be deployed as plan-specific pre-treatment QA tool to screen for errors. It is recommended to support the fluence integrated portal dosimetry QA by independent phantom-based measurements of a random sample survey of treatment plans.

Volumetric modulated arc therapy for hippocampal-sparing prophylactic cranial irradiation: Planning comparison of Halcyon and C-arm accelerators

Background

The purpose of the study was to evaluate the dosimetry of the Halcyon in prophylactic cranial irradiation (PCI) with volumetric modulated arc therapy (VMAT) and hippocampal-sparing for small cell lung cancer (SCLC).

Methods

Five VMAT plans were designed on CT images of 15 patients diagnosed with SCLC and received PCI. Three plans with two full arcs were generated on the Trilogy and the TrueBeam accelerators, and flattening filter (FF) and flattening filter free (FFF) modes were used on TrueBeam. Two Halcyon plans with two and three full arcs were generated, referred to as H-2A and H-3A, respectively. The prescription dose was 25 Gy in 2.5-Gy fractions. The dose limit for hippocampus were D₁₀₀ ≤ 9Gy and D_max ≤ 16Gy. The Wilcoxon matched-paired signed-rank test was used to evaluate the significance of the observed differences between the five plans.

Results

H-2A plans significantly increased the D₂ of PTV, and H-3A plans showed comparable or even better target dosimetry (better conformity) compared to the three plans on C-arm accelerators. Compared to T and TB plans, the two Halcyon plans significantly reduced the D₁₀₀ and mean doses of bilateral hippocampus, the mean doses of eyeballs, and the maximum doses of lenses. D₁₀₀ of hippocampus was reduced in TrueBeam plans comparing to Trilogy plans. The FFF plans on TrueBeam also represented advantages in D_mean and D₁₀₀ of hippocampas, D_mean and D_max of eyeballs, and the D_max of lenses compared to FF plans. Halcyon plans and TrueBeam plans with FFF mode increased the MUs compared to FF plans. Comparing to H-2A, the H-3A plans exhibited additional dosimetric advantages, including D₂, CI and HI of PTV, as well as the maximum and mean doses of hippocampus and eyeballs, and the maximum doses of optic nerves and brainstem. The two Halcyon plans significantly reduced the delivery time and showed the higher gamma passing rate than the three plans of C-arm accelerators.

Conclusions

Compared with the C-arm accelerators, the dose of hippocampus and the delivery times on Halcyon are relatively significantly reduced for hippocampal-sparing PCI. Three arcs are recommended for VMAT plans with the Halcyon in hippocampal-sparing PCI.

AAPM MEDICAL PHYSICS PRACTICE GUIDELINE 5.b: Commissioning and QA of treatment planning dose calculations-Megavoltage photon and electron beams

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines:

Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. While must is the term to be used in the guidelines, if an entity that adopts the guideline has shall as the preferred term, the AAPM considers that must and shall have the same meaning.

Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Investigation on the impact of the leaf trailing effect using the Halcyon integrated platform system

PURPOSE

The double-stacked design of the Halcyon multileaf collimator (MLC) presents new challenges for treatment planning systems (TPSs). The leaf trailing effect has recently been described as the result of the interplay between the fluence transmitted through the leaf tip ends of each MLC layer. This effect makes the dosimetric leaf gap (DLG) dependent on the distance between the leaves of different layers (trailing distance) and is not adequately modeled by the Eclipse TPS. The purpose of our study was to investigate and report the dose discrepancies produced by these limitations in clinical plans and to explore how these discrepancies can be mitigated and avoided.

METHODS

The integrated platform with the Halcyon v2 system, Eclipse and Aria v15.6, was used. The dose discrepancies were obtained with EPID images and the portal dosimetry software and validated using radiochromic film dosimetry. The results for the AIDA commissioning test and for nine selected clinical beams with the sliding window intensity modulated radiotherapy (dIMRT) technique were thoroughly analyzed and presented. First, the DICOM RT plans were exported and the fluences were computed using different leaf tip models, and then were compared. Second, the detailed characteristics of the corresponding leaf sequences were investigated. Finally, modified DICOM RT plans were created in which the non-collimating (backup) leaves were retracted 2 mm to increase the leaf trailing distance, the modified plans were imported back into the TPS and the measurements were repeated. Dedicated in-house tools were developed in Python to carry out all analyses.

RESULTS

Dose discrepancies greater than 10% and regions of gamma failure were found in both the AIDA test and clinical beams using static-gantry dIMRT. Fluence analysis highlighted that the discrepancies were due to limitations in the MLC model implemented in the TPS. Analysis of leaf sequences indicated that regions of failure were associated with very low leaf speeds and virtually motionless leaves within the beam aperture. Some of these discrepancies were mitigated by increasing the trailing distance of the non-collimating leaves without affecting the beam aperture, but this strategy was not possible in regions where the leaves from both layers actively defined the beam aperture.

CONCLUSIONS

Current limitations of the MLC model in Eclipse produced discrepancies between calculated and delivered doses in clinical beams that caused plan-specific quality assurance failures and interruptions in the clinical workflow. Careful evaluation of the clinical plans produced by Eclipse for the Halcyon is recommended, especially for static gantry dIMRT treatments. Some characteristics of leaf sequences are problematic and should be avoided in clinical plans and, in general, a better leaf tip model is needed. This is particularly important in adaptive radiotherapy treatments, where the accuracy and reliability of TPS dose calculations are of the utmost importance.

Automated treatment planning of prostate stereotactic body radiotherapy with focal boosting on a fast-rotating O-ring linac: Plan quality comparison with C-arm linacs

PURPOSE

The integration of auto-segmentation and automated treatment planning methods on a fast-rotating O-ring linac may improve the time efficiency of online adaptive radiotherapy workflows. This study investigates whether automated treatment planning of prostate SBRT with focal boosting on the O-ring linac could generate plans that are of similar quality as those obtained through manual planning on clinical C-arm linacs.

METHODS

For 20 men with prostate cancer, reference treatment plans were generated on a TrueBeam STx C-arm linac with HD120 MLC and a TrueBeam C-arm linac with Millennium 120 MLC using 6 MV flattened dual arc VMAT. Manual planning on the Halcyon fast-rotating O-ring linac was performed using 6 MV FFF dual arc VMAT (HA2-DL10) and triple arc VMAT (HA3-DL10) to investigate the performance of the dual-layer MLC system. Automated planning was performed for triple arc VMAT on the Halcyon linac (ET3-DL10) using the automated planning algorithms of Ethos Treatment Planning. The prescribed dose was 35 Gy to the prostate and 30 Gy to the seminal vesicles in five fractions. The iso-toxic focal boost to the intraprostatic tumor nodule(s) was aimed to receive up to 50 Gy. Plan deliverability was verified using portal image dosimetry measurements.

RESULTS

Compared to the C-arm linacs, ET3-DL10 shows increased seminal vesicles PTV coverage (D99% ) and reduced high-dose spillage to the bladder (V37Gy ) and urethra (D0.035cc ) but this came at the cost of increased high-dose spillage to the rectum (V38Gy ) and a higher intermediate dose spillage (D2cm). No statistically significant differences were found when benchmarking HA2-DL10 and HA3-DL10 with the C-arm linacs. All plans passed the patient-specific QA tolerance limit.

CONCLUSIONS

Automated planning of prostate SBRT with focal boosting on the fast-rotating O-ring linac is feasible and achieves similar plan quality as those obtained on clinical C-arm linacs using manual planning.

Sensitivity and specificity analysis of 2D small field measurement array: Patient-specific quality assurance of small target treatments and spatially fractionated radiotherapy

Purpose

The aim of this paper is to describe the tests carried out on a SRSMapCheck array, to verify its reliability and sensitivity for quality assurance (QA) of high gradient treatments as an alternative system to the use of high spatial resolution detectors, such as gafchromic film, whose processing requires meticulous and time‐consuming procedures.

Methods

In an initial step, general functionality tests were carried out to verify that the equipment meets the manufacturer's specifications. A study of the accuracy of the application of correction factors to compensate for variation in detector response due to dose rate, field size and beam angle incidence has been included. Besides, to assess the ability of the array to detect inaccurately delivered treatments, systematic errors corresponding to the deviation in the position of the leaves and the accuracy of the gantry position, have been introduced. Based on these results, an estimate of sensitivity and specificity values of the device has been completed. The final step included a study applied to high gradient treatment for real cases of spatially fractionated radiotherapy, where the results of SRSMapCheck measurements have been compared with gafchromic films.

Results

General commissioning tests meet the manufacturer's specifications. dose rate (DR) response variation is better than 1.5% and for DR above 50 MU/min better than 1%. The results for beam incidences are better than 1% for all gantry angles, including beam incidences parallel to the array. Field size response differences are within the range of ±1% for sizes up to 2 × 2 cm², with a maximum value obtained of 3.5%, for 1 × 1 cm². From the systematic error study, using a Gamma function Γ (2%, 2 mm), the detector presents a high specificity with a value greater than 90% at its lower limit, while its sensitivity has a moderate mean value of 81%. Sensitivity values increase above 86% when we apply a Gamma function Γ (2%, 1 mm) is applied. Finally, the study of actual cases comprises 17 patients, distributed into 11 lung tumors, 3 gynecological and 3 soft tissue tumors. The gafchromic film showed a lower passing rate with an average value of Γ (2%, 2 mm) = 94.1% compared to Γ (2%, 2 mm) = 98.6% reached by the measurements with the array.

Conclusions

Gamma function obtained with the SRSMapCheck array always presented a higher value than gafchromic film measurements, resulting in a greater number of plans considered correct. This fact, together with the sensitivity and specificity study carried out, allows us to conclude the recommendation that a restrictive metric must be established, in this way we will improve sensitivity, and therefore we will reduce the rate of incorrect plans qualified as correct. The characteristics of the equipment together with the correction factors applied, led to reliably performing acquisitions for complex treatments with multiple small targets in oblique rotational incidences. The spatial resolution of detectors allows the verification of high gradient dose plans such as those achieved in spatially fractionated radiotherapy (SFRT).

Dosimetric leaf gap and leaf trailing effect in a double-stacked multileaf collimator

PURPOSE

To investigate (i) the dosimetric leaf gap (DLG) and the effect of the "trailing distance" between leaves from different multileaf collimator (MLC) layers in Halcyon systems and (ii) the ability of the currently available treatment planning systems (TPSs) to approximate this effect.

METHODS

DICOM plans with transmission beams and sweeping gap tests were created in Python for measuring the DLG for each MLC layer independently and for both layers combined. In clinical Halcyon plans both MLC layers are interchangeably used and leaves from different layers are offset, thus forming a trailing pattern. To characterize the impact of such configuration, new tests called "trailing sweeping gaps" were designed and created where the leaves from one layer follow the leaves from the other layer at a fixed "trailing distance" t between the tips. Measurements were carried out on five Halcyons SX2 from different institutions and calculations from both the Eclipse and RayStation TPSs were compared with measurements.

RESULTS

The dose accumulated during a sweeping gap delivery progressively increased with the trailing distance t . We call this "the trailing effect." It is most pronounced for t between 0 and 5 mm, although some changes were obtained up to 20 mm. The dose variation was independent of the gap size. The measured DLG values also increased with t up to 20 mm, again with the steepest variation between 0 and 5 mm. Measured DLG values were negative at t  = 0 (the leaves from both layers at the same position) but changed sign for t  ≥ 1 mm, in line with the positive DLG sign usually observed with single-layer rounded-end MLCs. The Eclipse TPS does not explicitly model the leaf tip and, as a consequence, could not predict the dose reduction due to the trailing effect. This resulted in dose discrepancies up to +10% and -8% for the 5 mm sweeping gap and up to ±5% for the 10 mm one depending on the distance t . RayStation implements a simple model of the leaf tip that was able to approximate the trailing effect and improved the agreement with measured doses. In particular, with a prototype version of RayStation that assigned a higher transmission at the leaf tip the agreement with measured doses was within ±3% even for the 5 mm gap. The five Halcyon systems behaved very similarly but differences in the DLG around 0.2 mm were found across different treatment units and between MLC layers from the same system. The DLG for the proximal layer was consistently higher than for the distal layer, with differences ranging between 0.10 mm and 0.24 mm.

CONCLUSIONS

The trailing distance between the leaves from different layers substantially affected the doses delivered by sweeping gaps and the measured DLG values. Stacked MLCs introduce a new level of complexity in TPSs, which ideally need to implement an explicit model of the leaf tip in order to reproduce the trailing effect. Dynamic tests called "trailing sweeping gaps" were designed that are useful for characterizing and commissioning dual-layer MLC systems.

Technical Note: Self-shielding evaluation and radiation leakage measurement of a jawless ring gantry linac with a beam stopper

PURPOSE

To characterize the shielding design and leakage radiation from a newly released ring gantry linac (Halcyon, Varian Medical Systems).

METHODS

To assess the radiation leakage surrounding headshield and the radiation level after the beam stopper, measurements were made with GafChromic films. To evaluate the in-room radiation levels, the radiation leakage in the isocenter plane was measured with a large volume spherical ionization chamber (Exradin A6, Standard Imaging). A lead enclosure was constructed to shield the chamber from the low energy scatter radiation from the room. The radiation level at multiple locations was measured with the MLC fully closed and gantry at 0, 45, 90, 135, 180, 225, 270, and 315 degrees. The leakage radiation passing through multiple concrete slabs with various thickness was recorded in a narrow beam geometry to determine the tenth value layer (TVL).

RESULTS

A uniform leakage (<0.05%) at 1 m from electron beam line was measured surrounding the linac head with the maximum leakage measured at the top of the head enclosure. The highest radiation level (<0.08%) was measured near the edge of the beam stopper when projected to the measurement plane. The maximum radiation levels due to the head leakage at 15 locations inside the treatment room were recorded and a radiation map was plotted. The maximum leakage was measured at points that along the electron beam line while the gantry at 90 or 270 degree and at the end of head enclosure (0.314%, 0.4 m from electron beamline). The leakage TVL value is found to be 226 mm in a narrow beam geometry with the concrete density of 2.16 g/cm³ or 134.6 lb/cu.ft.

CONCLUSION

An overall uniform leakage was measured surrounding linac head. The beam stopper shields the primary radiation with the highest valued measured near the edge of beam stopper. The leakage TVL values are derived and less than the values reported for conventional C-arm linac.

Unlocking a closed system: dosimetric commissioning of a ring gantry linear accelerator in a multivendor environment

The Halcyon™ platform is self‐contained, combining a treatment planning (Eclipse) system TPS) with information management and radiation delivery components. The standard TPS beam model is configured and locked down by the vendor. A portal dosimetry‐based system for patient‐specific QA (PSQA) is also included. While ensuring consistency across the user base, this closed model may not be optimal for every department. We set out to commission independent TPS (RayStation 9B, RaySearch Laboratories) and PSQA (PerFraction, Sun Nuclear Corp.) systems for use with the Halcyon linac. The output factors and PDDs for very small fields (0.5 × 0.5 cm²) were collected to augment the standard Varian dataset. The MLC leaf‐end parameters were estimated based on the various static and dynamic tests with simple model fields and honed by minimizing the mean and standard deviation of dose difference between the ion chamber measurements and RayStation Monte Carlo calculations for 15 VMAT and IMRT test plans. Two chamber measurements were taken per plan, in the high (isocenter) and lower dose regions. The ratio of low to high doses ranged from 0.4 to 0.8. All percent dose differences were expressed relative to the local dose. The mean error was 0.0 ± 1.1% (TG119‐style confidence limit ± 2%). Gamma analysis with the helical diode array using the standard 3%Global/2mm criteria resulted in the average passing rate of 99.3 ± 0.5% (confidence limit 98.3%–100%). The average local dose error for all detectors across all plans was 0.2% ± 5.3%. The ion chamber results compared favorably with our recalculation with Eclipse and PerFraction, as well as with several published Eclipse reports. Dose distribution gamma analysis comparisons between RayStation and PerFraction with 2%Local/2mm criteria yielded an average passing rate of 98.5% ± 0.8% (confidence limit 96.9%–100%). It is feasible to use the Halcyon accelerator with independent planning and verification systems without sacrificing dosimetric accuracy.

Simplified sigmoidal curve fitting for a 6 MV FFF photon beam of the Halcyon to determine the field size for beam commissioning and quality assurance

Background

An O-ring gantry-type linear accelerator (LINAC) with a 6-MV flattening filter-free (FFF) photon beam, Halcyon, includes a reference beam that contains representative information such as the percent depth dose, profile and output factor for commissioning and quality assurance. However, because it does not provide information about the field size, we proposed a method to determine all field sizes according to all depths for radiation therapy using simplified sigmoidal curve fitting (SCF).

Methods

After mathematical definition of the SCF using four coefficients, the defined curves were fitted to both the reference data (RD) and the measured data (MD). For good agreement between the fitting curve and the profiles in each data set, the field sizes were determined by identifying the maximum point along the third derivative of the fitting curve. The curve fitting included the field sizes for beam profiles of 2 × 2, 4 × 4, 6 × 6, 8 × 8, 10 × 10, 20 × 20 and 28 × 28 cm² as a function of depth (at 1.3, 5, 10 and 20 cm). The field size results from the RD were compared with the results from the MD using the same condition.

Results

All fitting curves show goodness of fit, R², values that are greater than 0.99. The differences in field size between the RD and the MD were within the range of 0 to 0.2 cm. The smallest difference in the field sizes at a depth of 10 cm, which is a surface-to-axis distance, was reported.

Conclusion

Application of the SCF method has been proven to accurately capture the field size of the preconfigured RD and the measured FFF photon beam data for the Halcyon system. The current work can be useful for beam commissioning as a countercheck methodology to determine the field size from RD in the treatment planning system of a newly installed Halcyon system and for routine quality assurance to ascertain the correctness of field sizes for clinical use of the Halcyon system.

A Bayesian control chart based on the beta distribution for monitoring the two-dimensional gamma index pass rate in the context of patient-specific quality assurance

PURPOSE

In the context of quality assurance in intensity modulated radiation therapy (IMRT), the aim of this work was two-fold: (a) to show that the beta distribution characterizes the two-dimensional gamma index pass rate (GIPR), and that the quantiles of the distribution should be used in order to compute the control limit (CL) for the detection of abnormally low GIPR, and (b) to introduce a Bayesian control chart that allows calculation of CLs from the first measurement.

METHODS

In order to enable monitoring of the GIPR from the first measurement, we developed a Bayesian control chart based on the beta distribution, elaborated according to the following two steps: (a) an iterative bayesian inference approach without any prior information on the GIPR distribution was used at the start of monitoring and the CL was progressively updated; and (b) when sufficient in-control arcs had been recorded and the estimators of the parameters of the beta distribution were sufficiently accurate, the CL of the chart was fixed to a constant value corresponding to the quantile of the beta distribution. The clinical utility of this approach is illustrated through a real data case study: monitoring the GIPR of patients treated with a moving gantry IMRT technique RapidArc^TM on a Novalis TrueBeam STx (Varian Medical Systems) linear accelerator equipped with an aS1200 electronic portal imager device.

RESULTS

We showed that some commonly used distributions for monitoring GIPR in the literature, such as normal or logarithm transformation, are not appropriate. We compared the CLs of those solutions with the CL of our chart based on the BD (CL = 95.14%). The comparison revealed that the CL for the normal law (CL = 97.62%) generated too many false positives, and that the CL of the Logarithm transformation (CL = 83.74%) could fail to efficiently detect (i.e., sufficiently early on or faster) changes in the process.

CONCLUSIONS

Successful GIPR monitoring requires careful and rigorous application of well-established statistical concepts in the field of statistical process control. In this paper, we stress the importance of carefully analyzing the distribution of the monitored characteristic that is plotted on the control chart. We propose a Bayesian control chart that can be viewed as a practical solution for early implementation of GIPR monitoring, starting from the first arc. We demonstrate that beta distribution is a better method for characterizing the GIPR, and thus, the use of this approach is expected to improve patient-specific quality assurance plans in radiotherapy.

Automated and robust beam data validation of a preconfigured ring gantry linear accelerator using a 1D tank with synchronized beam delivery and couch motions

PURPOSE

To develop an efficient and automated methodology for beam data validation for a preconfigured ring gantry linear accelerator using scripting and a one-dimensional (1D) tank with automated couch motions.

MATERIALS AND METHODS

Using an application programming interface, a program was developed to allow the user to choose a set of beam data to validate with measurement. Once selected the program generates a set of instructions for radiation delivery with synchronized couch motions for the linear accelerator in the form of an extensible markup language (XML) file to be delivered on the ring gantry linear accelerator. The user then delivers these beams while measuring with the 1D tank and data logging electrometer. The program also automatically calculates this set of beams on the measurement geometry within the treatment planning system (TPS) and extracts the corresponding calculated dosimetric data for comparison to measurement. Once completed the program then returns a comparison of the measurement to the predicted result from the TPS to the user and prints a report. In this work lateral, longitudinal, and diagonal profiles were taken for fields sizes of 6 × 6, 8 × 8, 10 × 10, 20 × 20, and 28 × 28 cm² at depths of 1.3, 5, 10, 20, and 30 cm. Depth dose profiles were taken for all field sizes.

RESULTS

Using this methodology, the TPS was validated to agree with measurement. All compared points yielded a gamma value less than 1 for a 1.5%/1.5 mm criteria (100% passing rate). Off axis profiles had >98.5% of data points producing a gamma value <1 with a 1%/1 mm criteria. All depth profiles produced 100% of data points with a gamma value <1 with a 1%/1 mm criteria. All data points measured were within 1.5% or 2 mm distance to agreement.

CONCLUSIONS

This methodology allows for an increase in automation in the beam data validation process. Leveraging the application program interface allows the user to use a single system to create the measurement files, predict the result, and then compare to actual measurement increasing efficiency and reducing the chance for user input errors.

Technical Note: Flattening filter free beam from Halcyon linac: Evaluation of the profile parameters for quality assurance

INTRODUCTION

The use of flattening filter free (FFF) beams generated by standard linear accelerators is increasing in the clinical practice. The radiation intensity peaked toward the beam central axis is properly managed in the optimization process of treatment planning through intensity modulation. Specific FFF parameters for profile analysis, as unflatness and slope for FFF beams, based on the renormalization factor concept has been introduced for quality assurance purposes. Recently, Halcyon, an O-ring based linear accelerator equipped with a 6 MV FFF beam only has been introduced by Varian.

METHODS

Renormalization factors and related fit parameters according to Fogliata et al. ["Definition of parameters for quality assurance of FFF photon beams in radiation therapy," Med. Phys. 39, 6455-6464 (2012)] have been evaluated for the 6 MV FFF beam generated by Halcyon units. The Halcyon representative beam data provided by Varian were used. Dose fall-off at the field edges was matched with an unflattened beam generated by a 6 MV from a TrueBeam linac. Consistency of the results was evaluated against measurements on a clinical Halcyon unit, as well as a TrueBeam 6 MV FFF for comparison.

RESULTS

The five parameters in the analytical equation for estimating the renormalization factor were determined with an R² of 0.997. The comparison of the unflatness parameters between the Halcyon representative and hospital beam data was consistent within a range of 0.6%. Consistently with the computed parameters, the Halcyon profiles resulted in a less pronounced peak than TrueBeam.

CONCLUSION

Renormalization factors and related fit parameters from the 6 MV FFF beam generated by the Varian Halcyon unit are provided.

Comprehensive validation of halcyon 2.0 plans and the implementation of patient specific QA with multiple detector platforms

Purpose

To perform a comprehensive validation of plans generated on a preconfigured Halcyon 2.0 with preloaded beam model, including evaluations of new features and implementing the patient specific quality assurance (PSQA) process with multiple detectors.

Methods

A total of 56 plans were generated in Eclipse V15.6 (Varian Medical System) with a preconfigured Halcyon treatment machine. Ten plans were developed via the AAPM TG‐119 test suite with both IMRT and VMAT techniques. 34 clinically treated plans using C‐arm LINAC from 24 patients were replanned on Halcyon using IMRT or VMAT techniques for a variety of sites including: brain, head and neck, lung, breast, abdomen, and pelvis. Six of those plans were breast VMAT plans utilizing the extended treatment field technique available with Halcyon 2.0. The dynamically flattened beam (DFB), another new feature on Halcyon 2.0, was also used for an AP/PA spine and four field box pelvis, as well as ten 3D breast plans. All 56 plans were measured with an ion chamber (IC), film, portal dosimetry (PD), ArcCHECK, and Delta4. Tolerance and action limits were calculated and compared to the recommendations of TG‐218.

Results

TG‐119 IC and film confidence limits met those set by the task group, except for IMRT target point dose. Forty‐four of 46 clinical plans were within 3% for IC measurements. Average gamma passing rates with 3% dose difference and 2mm distance‐to‐agreement for IMRT/VMAT plans were: Film – 96.8%, PD – 99.9%, ArcCHECK – 99.1%, and Delta4 – 99.2%. Calculated action limits were: Film – 86.3%, PD – 98.4%, ArcCHECK – 96.1%, and Delta4 – 95.7%. Extended treatment field technique was fully validated and 3D plans with DFB had similar results to IMRT/VMAT plans.

Conclusion

Halcyon plan deliveries were verified with multiple measurement devices. New features of Halcyon 2.0 were also validated. Traditional PSQA techniques and process specific tolerance and action limits were successfully implemented.

Dosimetric Characterization of the Dual Layer MLC System for an O-Ring Linear Accelerator

The Halcyon is Varian’s latest linear accelerator that offers a single 6X flattening-filter-free beam with a jawless design that features a new dual layer multileaf collimator system with faster speed and reduced transmission. Dosimetric characteristics of the dual layer multileaf collimator system including transmission, dosimetric leaf gap, and tongue and groove effects were measured. Ionization chambers, diode arrays, and an electronic portal imaging device were used to measure various multileaf collimator characteristics. Transmission through both multileaf collimator banks was found to be 0.008%, while the distal and proximal banks alone had transmission values of 0.4%. The penumbra was slightly sharper for fields using only the distal multileaf collimator bank but found to be largely independent of leaf position with values between 2.7 to 3.0 mm at d_max for the combined multileaf collimator banks. The dosimetric leaf gap was measured for the proximal and distal multileaf collimator banks both individually and together and found to have values of −0.216 mm, −0.225 mm, and 0.964 mm, respectively. Measurements of dosimetric leaf gap at the leaf edge and midline were also performed. Tongue and groove effects were investigated with both the electronic portal imaging device and a 2-dimensional array of diodes.

Treatment planning comparison of volumetric modulated arc therapy employing a dual-layer stacked multi-leaf collimator and helical tomotherapy for cervix uteri

Purpose

To ascertain the dosimetric performance of a new delivery system (the Halcyon system, H) equipped with dual-layer stacked multi-leaf collimator (MLC) for risk-adapted targets in cervix uteri cancer patients compared to another ring-based system in clinical operation (Helical Tomotherapy, HT).

Methods

Twenty patients were retrospectively included in a treatment planning study (10 with positive lymph nodes and 10 without). The dose prescription (45Gy to the primary tumour volume and a simultaneously integrated boost up to 55Gy for the positive patients) and the clinical planning objectives were defined consistently as recommended by an ongoing multicentric clinical trial. Halcyon plans were optimised for the volumetric modulated arc therapy. The plan comparison was performed employing the quantitative analysis of the dose-volume histograms.

Results

The coverage of the primary and nodal target volumes was comparable for both techniques and both subsets of patients. The primary planning target volume (PTV) receiving at least 95% of the prescription isodose ranged from 97.2 ± 1.1% (node-negative) to 99.1 ± 1.2% (node-positive) for H and from 96.5 ± 1.9% (node-negative) to 98.3 ± 0.9% (node-positive) for HT. The uncertainty is expressed at one standard deviation from the cohort of patient per each group. For the nodal clinical target volumes, the dose received by 98% of the planning target volume ranged 55.5 ± 0.1 to 56.0 ± 0.8Gy for H and HT, respectively. The only significant and potentially relevant differences were observed for the bowels. In this case, V_40Gy resulted 226.3 ± 35.9 and 186.9 ± 115.9 cm³ for the node-positive and node-negative patients respectively for Halcyon. The corresponding findings for HT were: 258.9 ± 60.5 and 224.9 ± 102.2 cm³. On the contrary, V_15Gy resulted 1279.7 ± 296.5 and 1557.2 ± 359.9 cm³ for HT and H respectively for node-positive and 1010.8 ± 320.9 versus 1203.8 ± 332.8 cm³ for node-negative.

Conclusion

This retrospective treatment planning study, based on the dose constraints derived from the Embrace II study protocol, suggested the essential equivalence between Halcyon based and Helical Tomotherapy based plans for the intensity-modulated rotational treatment of cervix uteri cancer. Different levels of sparing were observed for the bowels with H better protecting in the high-dose region and HT in the mid-low dose regions. The clinical impact of these differences should be further addressed.

A Method of High-Resolution Radiotherapy Delivery Fluences with a Pair of Fields with Orthogonal Collimator Settings: A Study on Ten Head-and-Neck Cancer Patients

Context:

Introduction of dual-layer multileaf collimator (MLC) radiotherapy linear accelerators into clinical practice is an important development in advanced external beam radiotherapy. A method of delivering comparable high-resolution fluences with a single-layer MLC is presented.

Aims:

The aims of this study are to present new algorithms and approaches to define high-resolution hypermodulated fluences, obtain orthogonal decomposition of fluences, and deliver them on a linear accelerator with single MLC from two perpendicular collimator settings.

Materials and Methods:

High-resolution fluences were defined using Monte Carlo (MC) calculation. A novel use of a limited-memory, bounded, Broyden–Fletcher–Goldfarb–Shanno algorithm was used to decompose such fluences to ones deliverable with a pair of fields with mutually orthogonal collimator settings. Such a technique, here named cross motion leaf calculator (XMLC), is compared against single sliding window (SSW) technique typically used in intensity-modulated radiation therapy (IMRT). An electronic portal imaging device (EPID) is used, and the results were compared with gamma analysis. Furthermore, MC was used to determine dose distributions for computed tomography images of ten head-and-neck cancer patients.

Results:

Gamma analysis (3%, 3 mm) against ideal fluence is considerably more favorable to XMLC (94% ± 4%) versus SSW (76% ± 5%). Furthermore, the dose–volume histogram (DVH) analysis showed that XMLC enables delivery of fluences superior to that of IMRT and these results in clinically relevant enhancements in DVH results.

Conclusions:

At the time of writing of this study, there were more than 12,000 medical linear accelerators in clinical use, and XMLC can prove itself useful wherever linac is equipped with MLC but cannot delivery latest techniques, such as volumetric modulated arc therapy.

Early clinical experience with varian halcyon V2 linear accelerator: Dual-isocenter IMRT planning and delivery with portal dosimetry for gynecological cancer treatments

PURPOSE

Varian Halcyon linear accelerator version 2 (The Halcyon 2.0) was recently released with new upgraded features. The aim of this study was to report our clinical experience with Halcyon 2.0 for a dual-isocenter intensity-modulated radiation therapy (IMRT) planning and delivery for gynecological cancer patients and examine the feasibility of in vivo portal dosimetry.

METHODS

Twelve gynecological cancer patients were treated with extended-field IMRT technique using two isocenters on Halcyon 2.0 to treat pelvis and pelvic/or para-aortic nodes region. The prescription dose was 45 Gy in 25 fractions (fxs) with simultaneous integrated boost (SIB) dose of 55 or 57.5 Gy in 25 fxs to involved nodes. All treatment plans, pretreatment patient-specific QA and treatment delivery records including daily in vivo portal dosimetry were retrospectively reviewed. For in vivo daily portal dosimetry analysis, each fraction was compared to the reference baseline (1st fraction) using gamma analysis criteria of 4 %/4 mm with 90% of total pixels in the portal image planar dose.

RESULTS

All 12 extended-field IMRT plans met the planning criteria and delivered as planned (a total of 300 fractions). Conformity Index (CI) for the primary target was achieved with the range of 0.99-1.14. For organs at risks, most were well within the dose volume criteria. Treatment delivery time was from 5.0 to 6.5 min. Interfractional in vivo dose variation exceeded gamma analysis threshold for 8 fractions out of total 300 (2.7%). These eight fractions were found to have a relatively large difference in small bowel filling and SSD change at the isocenter compared to the baseline.

CONCLUSION

Halcyon 2.0 is effective to create complex extended-field IMRT plans using two isocenters with efficient delivery. Also Halcyon in vivo dosimetry is feasible for daily treatment monitoring for organ motion, internal or external anatomy, and body weight which could further lead to adaptive radiation therapy.

Plan quality comparison for cervical carcinoma treated with Halcyon and Trilogy intensity-modulated radiotherapy

Purpose: Varian Halcyon is a novel machine with dual-layer leaves, single flattening filter free (FFF) energy and an enclosed bore. The purpose of this study was to compare the differences in dosimetry and plan parameters of intensity-modulated radiation therapy (IMRT) plans between the Halcyon and Trilogy accelerators. Methods and Materials: A total of 30 IMRT plans from cervical carcinoma patients were retrospectively analyzed on the Trilogy and Eclipse v13.5 treatment planning systems (TPSs). For each patient, a new plan based on Halcyon was created with the same planning parameters and optimization constraints using the Eclipse Version 15.1 TPS. To compare plan qualities, dosimetry parameters regarding planning target volume (PTV), organs at risk (OARs), monitor unit (MU) efficiency, segment size and treatment time were evaluated. Evaluation of the helical diode array system was performed with gamma-index analysis. Results: The dose distribution of the target volume of the Halcyon and Trilogy plans showed no significant difference (p > 0.05). The mean doses of rectum and both femoral heads for Halcyon plans were significantly reduced compared to those for Trilogy plans (p < 0.05). Compared to Trilogy, Halcyon increased the number of MUs from 1542.9±248.3 MU to 2514.9±328.2 MU (p = 0.00) and decreased the delivery time from 11.28±1.36 min to 3.26±0.26 min (p = 0.00). The average segment areas of Halcyon plans for proximal and distal multileaf collimators (MLCs) were 42.1 ± 31.2 cm2 and 28.4 ± 23.7 cm2, respectively, and that of Trilogy plans was 27.3 ± 16.9 cm2. The mean gamma index (3 mm/3%) results for the Halcyon and Trilogy plans were 99.41±0.26 and 99.76±0.32 (p > 0.05), respectively. Conclusions: All Halcyon treatment plans were recognized as clinically acceptable and had statistically better OAR sparing with higher delivery efficiency. The Halcyon system exhibited fast treatment delivery of IMRT with good dosimetric agreement using ArcCHECK.

Experience in commissioning the halcyon linac

PURPOSE

This manuscript describes the experience of two institutions in commissioning the new Halcyon^TM platform. Its purpose is to: (a) validate the pre-defined beam data, (b) compare relevant commissioning data acquired independently by two separate institutions, and (c) report on any significant differences in commissioning between the Halcyon linear accelerator and other medical linear accelerators.

METHODS

Extensive beam measurements, testing of mechanical and imaging systems, including the multi-leaf collimator (MLC), were performed at the two institutions independently. The results were compared with published recommendations as well. When changes in standard practice were necessitated by the design of the new system, the efficacy of such changes was evaluated as compared to published approaches (guidelines or vendor documentation).

RESULTS

Given the proper choice of detectors, good agreement was found between the respective experimental data and the treatment planning system calculations, and between independent measurements by the two institutions. MLC testing, MV imaging, and mechanical system showed unique characteristics that are different from the traditional C-arm linacs. Although the same methodologies and physics equipment can generally be used for commissioning the Halcyon, some adaptation of previous practices and development of new methods were also necessary.

CONCLUSIONS

We have shown that the vendor pre-loaded data agree well with the independent measured ones during the commission process. This verifies that a data validation instead of a full-data commissioning process may be a more efficient approach for the Halcyon. Measurement results could be used as a reference for future Halcyon users.

Clinical safety assessment of the Halcyon system

PURPOSE

The Halcyon consists of precommissioned linear accelerator and treatment planning algorithms that were designed to simplify the acceptance, commissioning, and clinical workflow for image-guided intensity-modulated radiotherapy. The purpose of this work was to perform a comprehensive safety assessment for the clinical use of the Halcyon.

METHODS

Systems-Theoretic Process Analysis was used as the safety assessment tool. As part of the analysis, a number of control loops and control actions are created to describe system function. Safety is assessed by determining unsafe control actions and a corresponding list of causal scenarios that leads to accidents. The scope of the analysis was from the acceptance of the Halcyon to routine patient treatments. All aspects of treating patients were considered including the roles of physicians, physicists, dosimetrists, and therapists. The analysis was completed by four physicists with input from other members of the radiation therapy team. The causal scenarios were summarized using the causality categories from the consensus recommendations for incident learning database structures in radiation oncology (Med Phys, Vol. 39, No. 12, Dec 2012).

RESULTS

Twenty-three (23) control loops containing 52 control actions were created for the clinical use of the Halcyon. One hundred forty-four (144) unsafe control actions were identified with 385 associated causal scenarios. Twenty-seven percent (27%) of the causal scenarios were related to equipment technical issues, while 73% of the causal scenarios were predominantly related to procedural issues, human behavior, and organizational management.

CONCLUSIONS

For routine clinical use of closed or largely automated radiation therapy equipment, the majority of safety concerns is related to nontechnical issues. The Halcyon and other similar systems may present opportunities to streamline, reduce, or eliminate some traditional equipment commissioning and routine quality assurance activities in exchange for an increased focus on issues related to organizational management, procedures, and human behavior.